07100052CITY OF CUPERTLNO
BUILDING DIVISION PERNUT
eulLTr� /cap�VEssS�,TEVENS CREEK BLVD
OWNER'S NAME:
KCR DEVELOPMENT
ARCHTTECTIENGINEER:
u C Zp LICENSED CONTRACTOR'S DECLARATION
jU I hereby affirm that I am Eructed order provisions of Chapter 9 (commencing
_ with Sermon 7000) of Divitbn 3 of tbt Busuuess and Profession Code, and my license is
in full face and effect
2 J 25 License Class Lit. 0
g Date Canuactor
9 ~ ARCHrrECrS DECLARATION
I understand my plans shall be used u public retards
D'u
y ua Licensed Pmfc=anal
y OWNER -BUILDER DECLARATION
I hereby affirm that i am exempt from the Comractors License Law for the
C following reason. (Section 7031 S, Business and Professions Cade: Any city or county
S which requires a permit to construct alley, improve. demolish, or repair any structure
prior to its issuance, also sequins the applicant for such permit to file a signed statement
< that he is licensed pursuant to the provisions of the Contractors License Law (Chapter 9
F $ (commencing with Section 7000) of Division 3 of the Business and Professions Code) or
y that he is exempt then from and the basis for the alleged exemption. Any violation of
Sepion 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not mere than Gvw hundred dollars (S504
❑ L as owner of the property. or my unployen with wages as their sole compensation,
will do the wart. and the sty uct ue Is not intended at offered for sale (Sec. 7044, Business
and Professions Code: The Contractors License L.aw don not apply to an owner of
property who builds or 6Dproves thereon, and who don such work himself or through his
own employees, provided that such improvements are Dot inncnded or offered for ale If.
however, the building or improvement is sold within one year of corepictiat the owner -
builder will have site burden of proving that he did not build or improve for purpose of
ale.).
❑ L as owner of the property, am exclusively contracting with licraand Cntacwrs to
construct the project (Sec. 7044, Busnas and Professions Co(ka) The Contractors Li-
cense Law does not apply to an owner of property who builds or improves thereat, and,
who contracts for such pro th traelor(s) licensed pursuant to the Contractor's
IJcenm LAW.Cltarn I ,B&PC(
Date
W '$ Co AMO DECLARATION
I hereby am m under "ty of I am of the following declarations
❑ I haft and will maintain a CenpOcata of Consent to self -Insure forWorkers Compen-
sation, u provided for by Section 3700 of the Labor Code, for the parformance of the
work for which this permit is issued.
❑ I have and will maintain Workces Compm=dGn Insuutce, u required by Section
3700 of the Labor Code, for the performance of the work for which this permit Is iuuei
My Workers Compensation Insurance atria and Policy number ate:
TBD — TO BE DETERMINED
PERMIT NO.
07100052
PERMIT ISSUE DATE
04/09/2008
SANITARY NO. CONTROL NO.
BLIB.DING PEP Mrr INFO
BLDG ELECT PLUMB MECH
Job Description
T.I. MARUKAI MARKET—STRUCTURAL,TBAR,NON— BEARING
WALLS,TOILET CORE,E/M/P,2 HVAC UNITS —ALL
INTERIOR.
10/10/07 REFUNDED BY VISA $11,266.41. INCORRECT
Sq. Ft. Floor Area
36906008.g64
Carrier. Policy No.:
CERTIFICATE OF DaMMON FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be complded if the permit is rot one hundred dollars (S 100)
or less)
I certify that In the performantce of the work for which this permit is issued. 1 shall not
employ any petson i y r so as to become subjat to the Workai pn
I�v+s of
Alk
wppu
N(TL7 AP . u, eking Wls Certificate of Eumption, you Id
hecone subject to the Workes TMpensatims provisions of the Labor Codc, you must
Z forthwith nromply wtlb web provisions err Wis permit shall be deemed revoked.
O CONSTRucnoN L.ErmiNG AGENCY
V) I hereby &M m that there is a construction lending agency for the perromarta of
p: ; the wort for which this permit Is issued (Sur. 3097, Civ. C.)a Q Lender's Name
„z Lenders Address
U Q I certify that 1 have read this sppliadon and suit that rite above information is
V. ',—' correct. 1 agree to comply with all city and county ordinances and state laws relating to
C) SV" Wilding construction, and hereby authorizerepreserttadves of this city to enter upon the
a above-mendoned property for intpccf)ou purposes.
(We) agree to save. Indemnify and keep barmicss site City of Cupertino against
►F.t vy liabilities, judgments, cots and expo isea which may In any way acaoc against said City
() Z in consequence of the n"this permit.
'-" APPLicAmy UPIDF TtrA m WILL COMPLY WITH ALL NON -POINT sued by:
HAZARDOUS�TERIALS DISCLOSURE
WIB the applicant or flnwe Widing occnpust star or handle hazardous material
as defined by the Cupertino Municipal Code. Chapter 9.12. and the Health and Safety
Code, Section 25532(a)7
El Yes
Will the applicant or future building occupant use equipment or device which
emit harsrdoua air contaminants as defned by the Bay Area Air Quality Management
DiWict7
Yes No
Re -roofs
Type of Roof
$102000
Required Inspections
Date
Type
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
all new materials for inspection.
I have mad the hvsrdous nuteriI
rda Health & Safety Code. Scctjpnd7M
does not curremlylsave a tint that it
remems under (Lapuv &93 of the Califor-
ard W34.1 understand that if the building
aponsibility to notify the occupant of the
Signature of Applicant Date
. All roof coverings to be Class's' or better